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Sacral Nerve Stimulation

(Medtronic InterStim® Therapy for Urinary Control)

SNS Therapy: Test Stimulation and Implant

Sacral Nerve Stimulation(SNS) therapy is delivered in two procedures. The first is the test to see if the therapy will work for you. The next procedure, an implant of a SNS system, may be done if the test stimulation procedure was successful.

One of the biggest advantages of SNS is the test that allows you to try sacral nerve stimulation for several days. Once you have experienced the therapy, the surgeon will discuss the results of the test with you. If the test was successful, you along with the doctors will decide whether to have the complete system placed. The test involves placement of a lead (thin wire) that is placed near the sacral nerves. There will be a thin wire that exits your skin. This wire is connected to a small cable and test stimulator that is worn on a belt for the duration of the test at home. The test stimulator provides stimulation similar to that felt with the implant. This is an outpatient procedure done with mild sedation and local anesthesia only.

The next step, the implant of the SNS system, may be done after a successful test stimulation. It involves placement of a neurostimulator (electronics and battery). The implanted system is entirely under the skin

How is the Test for SNS Therapy Done?

Placing the Test Stimulation Lead

There are two types of leads used for test stimulation, a temporary lead or a long-term lead. Most surgeons typically use the long-term lead for test stimulation (Fig 4).

The test stimulation lead is inserted in the hospital or surgery center, depending upon the type of lead placed and/or your physician’s preference. Your doctor will explain the type of anesthesia that will be used for your procedure. The medical team will make you as comfortable as possible during the procedure. You may be given pain medication and a sedative that will make your feel relaxed and Dr.owsy, but able to cooperate during the procedure.

While you are lying on your stomach, the surgeon will insert a lead through a small needle and position it near a sacral nerve. The sacral nerves are located near the tailbone. During the procedure you may be asked to describe what you feel when the sacral nerve is stimulated. You may feel a “pulling”, “tingling” or “tapping” sensation in your pelvic muscles and movement of your big toe. Women may feel a sensation in the vaginal area and men in the scrotum. Patients go home shortly after the procedure.

• If a temporary lead was used, it will exit your skin in your lower back. It will be taped to your skin and attached to the external test stimulator that you wear when you go home (see figure 3).
• If a long-term lead is used, a small wire is attached to the lead. The wire exits a small incision in your lower back or upper buttock. This wire is connected to the external test stimulator that you wear when you go home (see figure 4).

At Home

You will go home with a temporary system to “test” how the therapy works for you. The test stimulator generates mild, carefully controlled electrical pulses that are carried to the sacral nerve. These pulses cause the sensations of “pulling” or “tingling” or “tapping” in your pelvic area like you felt during the placement of the lead. Stimulation sensations vary from person to person, but should be comfortable. You will be shown how to control the intensity of stimulation and how to turn the system ON or OFF.

While undergoing the test, you will document your symptoms in a voiding diary. In the diary you will record how much and how often you urinate, any leaking episodes and any symptoms of urgency and frequency. If you have urinary retention and catheterize to empty your bladder, you will record the volume and time you catheterized. If you have pain or fecal incontinence, you will monitor any improvement in your symptoms. During the test you will know how stimulation feels and if it improves your symptoms. If your urinary, bowel or pain symptoms improved during the test stimulation, you and your physician will decide if you want to continue with the therapy.

Your Follow-up Office Visit

After the test, you will meet with the doctors to review your voiding diary and discuss whether your symptoms improved. Be aware that your bladder control symptoms will most likely return within a few hours after stopping the test stimulation.

If your symptoms improved – You and your doctor will decide if the SNS therapy is appropriate for you. Generally, if you have no problems and your symptoms improved during the test stimulation, you may be a potential candidate for SNS therapy.

If your symptoms did NOT improve – If leads were placed on both sides (i.e. right and left) then the other lead may be tested, or both leads may be tested at the same time. If no result is seen with either lead or both at the same time, the doctors may try to repeat the test stimulation or reposition the leads in the hospital. Or, you and your doctor may decide to try another procedure or different therapy.

How is the Implant for SNS Therapy Done?

The InterStim® System for urinary control (made by Medtronic) is a sacral nerve stimulation system. The system includes a neurostimulator and lead that are surgically placed and programmers to adjust the stimulation settings.

Implanting the SNS Device

The implant procedure is performed in an operating room. As with the test stimulation procedure, the medical team will make you as comfortable as possible during the procedure. The same type of anesthesia will be used as the test stimulation, i.e. local numbing medication and mild sedation.

You will have one or two incisions. The incision made for the neurostimulator will be about 2 inches long; the other incision will be small, about ½ inch or less. The entire system will be under your skin. The surgeon will typically use the same incisions that were used for your test stimulation.

• If a temporary lead was used for the test stimulation:
• the lead will be removed
• a long-term lead and neurostimulator will be implanted in the upper buttock or abdomen
• If a long-term lead was used for the test stimulation (see figure 5):
• the long-term lead will remain in place
• the external wire used for test stimulation will be removed, and
• a neurostimulator will be connected to the long-term lead and placed under the skin in the upper buttock. The same incisions will be used from previously, however the one on the upper buttock will be slightly enlarged to place the stimulator.

After Surgery

You should be able to go home the same day of the procedure. Your incisions may feel sore and somewhat painful, especially during the first two weeks. The doctors may prescribe a medication to control your discomfort. As the incisions heal, you should become more comfortable and will be able to gradually increase your activity level. Your doctor or nurse will give you directions to follow after the surgery.

Your physician turns on the neurostimulator after surgery. When the system is turned ON, you will feel a slight tingling, tapping or pulling sensation similar to what you felt during the test stimulation. The sensation should not be painful. The level of stimulation will be increased or decreased to achieve the best control of your symptoms.

Adjusting the Level of Stimulation at Home

At home, you can control the level of stimulation and turn the SNS system ON and OFF with the patient programmer. The programmer is a hand-held device and is about the size of a cell phone (see Figure 6). When the programmer is held over the neurostimulator, the programmer “talks” to the neurostimulator to change the settings. (For more information, refer to technical manual or the Reference Card packaged with the InterStim System patient programmer.)

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